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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210087
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:20:03 PM

Document Has Been Signed on 05/16/2024 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FLORA'S HOMEFACILITY NUMBER:
419210087
ADMINISTRATOR/
DIRECTOR:		ANCHETA, KELLYFACILITY TYPE:
735
ADDRESS:1008 CORTEZ AVENUETELEPHONE:
(650) 315-2242
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator, Kelly AnchetaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On May 16, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up with an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit.

On May 10, 2024, the facility reported resident #1 (R1) AWOL (Absent Without Official Leave), R1 was found by the local law enforcement at the neighbor's yard and R1 was escorted back to the facility by the officer.

Facility conducted assessment and R1 did not sustained any injuries.

During today's visit, LPA interviewed the administrator who stated that R1 has a history of AWOL prior to R1's admission but has never had any attempts of AWOL except for this incident. The administrator stated that the facility did not install any security/auditory devices prior to this incident, but since the incident, auditory devices were installed on exit doors.

LPA toured the facility and observed auditory devices were install on 2 resident's rooms, the front door and the sliding door by the dining room.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D.
Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 12:20 PM - It Cannot Be Edited


Created By: Murial Han On 05/16/2024 at 11:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FLORA'S HOME
FACILITY NUMBER: 419210087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
80077.3(a)

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80077.3 Care for Clients Who Lack Hazard Awareness or Impulse Control..(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells,
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The facility has since installed auditory devices on exits door to prevent the incident from happening again.
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buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. This requirement is not met as evidenced by R1 left the facility unattended and the facility did not have any auditory devices on exterior doors which posed an immediate health risks to residents in care.
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Deficiency Cleared on 5/16/2024; LPA observed auditory devices were installed and in operating condition.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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